Provider Demographics
NPI:1609825488
Name:WHITSON, STEPHANIE MICHELLE (PHD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:MICHELLE
Last Name:WHITSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:W
Other - Last Name:VINSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:121 CARL VINSON PARKWAY
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088
Mailing Address - Country:US
Mailing Address - Phone:478-922-2365
Mailing Address - Fax:478-922-1778
Practice Address - Street 1:121 CARL VINSON PARKWAY
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088
Practice Address - Country:US
Practice Address - Phone:478-922-2365
Practice Address - Fax:478-922-1778
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY2818103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q27257Medicare UPIN
GA68BBGLCMedicare ID - Type Unspecified